Loro's Pilot program participation application
This application is designed to collect end user’s information that are required for the pilot program and product development. We will request for some of end user’s basic information such as Name, Email, Phone, Medical condition, Wheelchair information, organization association, basic medical expense funding options.
End user with disability
Product user information
Information about end user
Area Zip code
What is product user's medical condition
MS or Multiple Sclerosis
Quadriplegia or Spinal Cord Injury (C / T / L / S)
Syringomyelia / PMA / UMND
What age group does the end user belong to?
Children (0 - 14 Yrs)
Youth (15 - 24 Yrs)
Adult (25 - 64 Yrs)
Senior (65+ Yrs)
Medical condition if other please specify
Wheelchair and assistive devices
Basic wheelchair information and mobile or tablet device used
What smart devices are you using?
Android (Mobile / Tablet)
Echo / Alexa
Google mini / Google home
iOS (iPad / iPhone)
Lotron Smart home
Nest Smart home
Wink / Ecobee
Do you use any of the ability switches like
Eye tracking / Eye gaze device
Sip / Puff switch
Cushion grip switch
Ability switch if other please specify
Where is the wheelchair most likely be used?
About users, caretakers and finance options
This will help us reach the right service provider and stake holders to improve our product services
If you have a caregiver how many hours in a day will you need their help?
1 - 4 Hours a day
4 - 7 Hours a day
7 - 10 Hours a day
Approximately half a day
Almost the entire day
I don't need a caretaker
What activity do you expect your caregiver to help you with the most?
Eat / Drink
Transfer to and from Bed / Wheelchair
Transportation (Indoor / Outdoor)
All of the above
How much is your investment towards your medical devices and services per month?
Less than $100
$100 - $500
$500 - $1K
$1K - $2K
Greater than $2K
Do you use financial aid for your medical expenses from..
None / Self
Financial aid if you other specify
Where do you prefer to buy any of your assistive devices?
Online E-Commerce site
Local store or Medical supply store
Rent / Lease / Borrow from associations
Therapists / Doctors
Loro product demo
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